Tuesday, November 25th, 2014
Physician, Heal Thyself: Doctors in a Pluralist Democracy
By Daniel Sulmasy
This essay is the eleventh in a series exploring the role of the professions in a modern, liberal democratic society and their effect on the civic culture of the nation. For more information about AEI’s Program on American Citizenship, visit www.citizenship-aei.org.
Today’s physicians are a beleaguered bunch. They find themselves attempting to satisfy multiple conflicting demands, morally adrift, spiritually depleted, and politically powerless. They have become trapped in a vice, squeezed between the grips of the market and government, with no apparent escape. Public trust in US physicians is at an historic nadir, with the United States ranking 24th among 30 industrialized nations, ahead only of Chile, Bulgaria, Russia, and Poland. Morale is at an all-time low. Many are leaving the practice. Only a minority would recommend that their children become physicians.
Yet all this is happening at a time when medical care occupies a proportion of the economy that exceeds even defense, and when physicians’ technical powers and skills have never been greater. Smallpox has been eradicated. Breast cancer has become a chronic disease. Robots perform surgery. Life expectancy in the developed world is approaching biblical standards. Medicine seems so powerful.
And medicine’s cultural reach is as broad as it is deep. Medicine now colors nearly everything about our lives. We are so dependent on drugs that there seems to be a pharmacy on every other city street corner. We receive more and more vaccines, but we also live in constant fear of exotic infections. New medical devices have become big news for business. Stories about disease prevention with colonoscopies or prostate-specific antigen testing make the front pages of leading newspapers.
Furthermore, the US Supreme Court makes regular decisions about such medical topics as health care financing, the patenting of diagnostic tests, the mandating of insurance coverage for particular drugs and devices, and the conscience claims of practitioners and patients. Everyone knows someone whose death has involved a decision about whether to withhold or withdraw a life-sustaining treatment. Neuro-cognitively normal students take drugs to perform better on tests, and athletes take drugs to hit more home runs.
Medicine holds a preeminent place in the modern world. So why are physicians so unhappy?
The reasons are numerous and complex. First, and perhaps most salient, is the fact that increasing medical care costs have led those who pay for care—largely, government and private employers—to try to find ways to decrease health care expenditures through the regulation or manipulation of physician behavior or by decreasing payments. This has meant rising pressure on physicians to be more efficient and an increasingly burdensome bureaucratic system designed to implement the cost-cutting regulatory apparatus. The constant burden of regulation, paperwork, and appeals—and physicians’ growing weariness toward various attempts to alter their behavior by changing financial incentives and other behavior-modification techniques—weighs heavily on practitioners.
Second, these cost pressures lead physicians to see more patients (and to subsequently spend less time with each patient) just to maintain their levels of income. Those who value their relationship with patients are grieving the loss. And partly flowing from these cost pressures, but also owing to other sociocultural trends, physicians are being urged to change their focus from the care of individual patients to the care of populations of patients.
Since, as Aristotle once observed, physicians do not treat humankind but “Callius or Socrates or someone else” who is sick, the metaphysical impossibility of the task set before them has become a source of perplexity and angst at the bedside. Physicians (correctly) feel incapable of doing what they have been asked to do.
Third, the very technology that mediates medicine’s current prowess has become a source of alienation. For example, technology has long been a source of alienation for patients who feel increasingly treated as objects of it rather than respected as individuals. Patients are grateful for the technology that extends, saves, or improves their lives but question whether access to this technology requires that they sacrifice a sense of personal care.
Lesser known is the fact that clinicians are also now experiencing alienation from the technology that they deploy. An intuitive sense that medicine is more than applied technology haunts many practitioners, even as they see their time and attention increasingly focused on the chemical compounds, machines, calculations, and techniques of care and decreasingly on the persons this technology is intended to serve.
Fourth, the technology now empowers physicians to make interventions that once lay outside the purview of medicine, leading to questions about what medicine is for and what its goals might be: How long should human life be extended? Are there moral limits to what ought to be done to assist infertile couples? Is there a difference between giving growth hormone to a child who is short statured because of deficiency in that hormone versus giving it to a child with normal hormone levels but whose parents desire a taller child? Physicians are increasingly uncertain about what medicine is.
Fifth, the rise of consumerism in health care has amplified these questions. What began as an insistence on being informed and involved in decision making, including a right to refuse recommended medical interventions, has evolved into an ethic of informed (or sometimes uninformed) demand for interventions on the part of patients and families. Physicians were once, in an unjustified and paternalistic approach, the sole medical decision makers. Now, the pendulum has swung to the opposite extreme. Physicians have come to be considered providers of a consumer good that must be dispensed on demand. This negatively impacts physicians’ sense of themselves as independent professionals.
Compounding this consumerism as a cause of physician distress is the markedly litigious atmosphere that has come to surround the delivery of health care. Seven percent of physicians are sued each year (19 percent for neurosurgeons). By age 65, 75 percent of physicians in low-risk specialties (and 99 percent in high-risk specialties) will have been sued at least once.
In 2004, annual malpractice premiums for obstetricians averaged between $80,000 and $174,000 per year, leading many obstetricians to retire early or limit their practices to gynecology and cease delivering babies. Maintaining income is beside the point—they could always increase their fees. Physicians feel deeply hurt when sued for bad outcomes, even when they are not at fault.
Sixth, the information explosion has made it impossible to know all there is to know about medicine. This has made the generalist’s job far more difficult and has helped, in part, drive a subsidiary problem: hyper-specialization. Medicine is no longer a unified field with camaraderie across specialties, but rather a collection of specialists, subspecialists, and sub-subspecialists who know little about other aspects of medicine and who communicate poorly with colleagues in medicine outside their fields. As a result, care is fragmented and the whole patient is lost in the sea of subspecialists.
Generalists, who might be called on to coordinate the various aspects of care, lack the necessary information and control to exert much influence in this coordination and are made to feel inadequate and inferior. Compounding these matters, the remuneration scheme for medical practitioners overcompensates specialists and undercompensates generalists. Thus, the best and brightest new medical students want to be dermatologists, ophthalmologists, and radiologists, which are all highly compensated, procedure-oriented specialties with little on-call commitment and little investment in long-term patient relationships.
Seventh, the introduction of the electronic medical record (EMR) has not been an unqualified good. The EMR does facilitate communication among physicians about common patients and can warn physicians about drug interactions or prompt them to order routine periodic tests, such as mammograms. By and large, however, the EMR has become an instrument of the bureaucracy. It helps institutions capture language and codes that are required for billing and helps assure compliance with a host of regulations and insurer requirements.
Ironically, the EMR actually drives up health care costs because hospitals and private practices can now more readily prove that they provided the services for which they charge. In demanding all this documentation, the EMR has added to the bureaucratic burdens that physicians face. While it speeds up note writing, the drawback is that medical notes have become incomprehensible masses of undigested medical information. Patients complain that physicians now make more eye contact with computer monitors than with them. Physicians, in turn, feel more like clerks than professionals.
Numerous as they are, the abovementioned external factors are not the only causes of physician demoralization. Physicians have brought some of the demoralization on themselves. Rather than collectively resisting external forces deleterious to the profession and the public and suggesting constructive alternatives, physicians have by and large acted, both independently and collectively, in ways that seem to serve their own self-interests. For instance, rather than fighting against decreases in payment per visit, they have increased the number of visits and decreased time spent with patients. It is also physicians who have so emphasized science in medical education that the needs of patients as persons have been lost.